1141

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Duplex and Color Doppler

Sonographic Evaluation of
Vasculogenic Impotence

L
Jeffrey P. Quarn1 One hundred eighty patients with suspected vasculogenic
impotence were evaluated
Bernard F. King1 with conventional penile duplex sonography with analysis and color Doppler
spectral
E. Meredith James1 imaging. Measurements of mean peak systolic and end-diastolic velocities were ob-
tamed from the cavemosal arteries before and after intracavemosal injections of
Ronald W. Lewis2
papavenne. Sixty-one patients were examined with dynamic cavemosography and
Duane M. Brakke1
cavemosometry, and 12 patients were studied with selective internal pudendai and
Duane M. llstrup#{176} penile artenography. All five patients with abnormal arteriography had mean peak
Bhalchandra G. Parulkar2 systolic velocities in the cavernosal arteries of 25 cm/sec (sensitivity, 100%; 95%
Robert A. Hattery1 confidence interval, 48-100%) after the injection of papavenne. Six of the seven patients
with normal arteriography had mean peak systolic velocities of >25 cm/sec (specificity,
85.7%; 95% confidence interval, 42-100%) after injection of papaverine. By using data
from a receiver-operating-characteristic curve, we determined that end-diastolic veloc-
ities in the cavernosal arteries of 5 cm/sec after the injection of papaverine correctly
Identified patients with excessive venous leakage on cavernosometry; the sensitivity
was 90% (95% confidence interval, 77-97%) and the specificity was 56% (95% confi-
dence interval, 30-80%). The addition of color Doppler sonography made the detectIon
of vessels easier and the correction of the Doppler angle more accurate, resulting in
more rapid and accurate acquisition of data.
Penile duplex sonography with spectral analysis and color Doppler imaging are
sensitive and noninvasive means of examining patients with potential vasculogenic
impotence.

AJR 153:1141-1147, December 1989

Penile erection is a complex neurovascular event that has been the subject of
extensive clinical research [1 -6]. Proper neurochemical stimulation and end-organ
response are required to initiate penile vascular changes. Adequate arterial inflow
is necessary to meet the volume expansion of the dilated penile sinusoids. In
addition, sufficient restriction of venous outflow must be obtained to allow retention
Received May 5, 1989; accepted after revision
June 23, 1989. of penile perfusion and to produce rigidity. Clinical evaluation of erectile dysfunction
Presented at the annual meeting of the American
therefore should address all potential causes of impotence.
Roentgen Ray Society, New Orleans, May 1989. The introduction of penile duplex sonography in the evaluation of vasculogeniC
1 Department of Diagnostic Radiology, Mayo impotence has been useful in many studies [7-1 1]. These important studies used
Clinic and Mayo Foundation, 200 First St. SW., peak systolic velocities and diameters of the cavernosal arteries to assess penile
Rochester, MN 55905. Address reprint requests to
B. F. King. blood flow. We report our experience with the application of conventional duplex
2Dep&nt of Lkoiogy, Mayo Clinic and Mayo sonography along with color Doppler imaging for the noninvasive evaluation of
Foundation, Rochester, MN 55905. vasculogenic impotence. Peak systolic velocities and diameters of penile cavernosal
3Department of Biostatistics, Mayo Clinic and arteries were evaluated in relation to the results of color Doppler imaging. In
Mayo Foundation, Rochester, MN 55905. addition, end-diastolic velocities of the cavernosal arteries were evaluated as
0361-8O3X/89/1536-1 141 potentially valuable diagnostic measurements in distinguishing venous from arterial
© Amencan Roentgen Ray Society abnormality as the cause of impotence.
 1142 QUAM ET AL. AJR:153, December 1989
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Materials and Methods waveform was displayed on the monitor, and peak systolic and end-
diastolic velocities were measured and recorded by using the cursors.
One hundred eighty patients with suspected vasculogenic impo- Both cavernosal arteries were evaluated in all patients. After the
tence (age range, 1 8-82 years; mean, 56) were examined at the initial scan, 60 mg (2.0 ml) of papaverine was injected into the left
Mayo Clinic from October 1 987 through October 1 988. All patients corpus cavernosum by using a 25-gauge needle. After 5 mm to allow
initially were examined in the department of urology. A thorough uniform diffusion of and physiologic response to the papavenne,
history was obtained, a physical examination was performed, and scanning was performed again. All patients were observed after the
levels of free and total serum testosterone and glycosylated hemo- examination and left the department without any complications. in-
globin or glucose were determined. One hundred forty-seven patients structions were given to the patient to return to the urology depart-
also had evaluation of nocturnal penile tumescence and 120 had ment or emergency room if the erection did not subside within 3 hr
penile-brachial index studies. Seventy-eight of these patients had a or if excessive pain developed any time after the injection of
papavenne injection test in a urology office. Sixty-one patients were
papaverine.
examined with dynamic cavemosography and cavernosometry and
12 by selective internal pudendal and penile artenography. All patients
were studied with conventional duplex sonography with spectral
analysis and color Doppler imaging (Acuson, Mountain View, CA). A Results
5.0-MHz linear electronically focused transducer was used. The wall
filter was on the lowest setting so that frequency shifts of 125 Hz or The normal anatomy of the flaccid penis was seen clearly
less were not recorded on the velocity spectral display. on both transverse and longitudinal images. On transverse
The color Doppler imaging examination was performed with the views, the corpora cavernosa appeared as paired round or
patient supine and the penis in the anatomic position (i.e., with the
oval structures surrounded by the highly echogenic tunica
dorsum against the abdomen and the ventrum exposed)(Fig. 1). The
albuginea. The septum penis, an extension of the tunica
sonographic probe was placed on the ventral surface at the base of
the penis. The initial scan was obtained with the penis in the flaccid
albuginea, appeared as an echogenic line dividing the two
state; high-resolution real-time imaging was used to show anatomic corpora cavemosa. The cavernosal arteries could be identified
detail of the corpora cavernosa, cavernosal arteries, and surrounding in cross section by their echogenic walls and often by their
structures. Any gross pathologic processes, such as penile plaques pulsations. Their position was central within each corpus
(e.g., Peyronie disease), were ruled out at this time. Electronic cursors cavernosum or slightly eccentric toward the median septum
were used to measure the diameters of the cavernosal arteries in the penis. On longitudinal images, each corpus cavernosum ap-
longitudinal projection in the proximal penile shaft. Color Doppler peared as a low to moderately echogenic body with the highly
imaging was then performed to display blood flow through the echogenic tunica albuginea above and below it. All cavernosal
cavernosal arteries. By using the color image as a guide to the arteries were identified and evaluated. The diameters of the
location and direction of flowing blood, the Doppler sample volume
cavernosal arteries were measured in the longitudinal plane.
cursor was placed accurately in the cavemosal artery at the base of
the penis, and the Doppler angle correction cursor was adjusted to
They ranged from 0.2 to 1 .0 mm (average, 0.38) before
match the correct axis of flow. The resulting angle-corrected velocity injection of papavenne and from 0.2 to 1 .3 mm (average,
0.61) after injection. Color Doppler imaging was also per-
formed in the longitudinal plane. The mean peak systolic
velocities (the average of the peak velocity in the left and right
cavemosal arteries) were measured in all patients. These
ranged from 0 to 54 cm/sec (average, 13.8) before injection
of papaverine and from 9 to 1 1 0 cm/sec (average, 36.1) after
injection.
Pelvic arteriography was performed in 12 patients with
suspected arterial disease. Seven had arteriographically nor-
mal pudendal and penile arteries, and five had abnormal
vascularity with various degrees of arterial obstruction. These
results were compared with the sonographic findings (Fig. 2).
We assumed that a mean peak systolic velocity of greater
than 25 cm/sec after injection of papaverine indicated normal
arterial inflow [1 2]. All five patients with abnormal findings on
arteriography also had abnormal peak systolic velocities. Six
of the seven patients with normal arteriograms had normal
Doppler studies. The seventh patient had a postpapaverine
velocity of 24 cm/sec. This comparison yielded a sensitivity
of 100% (95% confidence interval, 48-1 00%), a specificity of
85.7% (95% confidence interval, 42-1 00%), and an overall
accuracy of 91.7% (95% confidence interval, 62.-i 00%) for
the evaluation of arterial insufficiency by duplex and color
Doppler sonography.
The evaluation of penile venous disease in impotence has
Fig. 1.-Position of penis during duplex Doppler sonographic evaluation.
Transducer is applied to ventral aspect of penis both before and after
been accomplished heretofore through dynamic cavernosom-
injection of papaverlne. etry and cavernosography. End-diastolic blood velocity in the
 AJR:153, December1989 DOPPLER OF VASCULOGENIC IMPOTENCE 1143
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60 30

50 25 ..
C)
C.) = C.,
8 20
C
.
- Mean 35.6 0
. U 90
c30
Median 31.0 15
§ C Median 19.0
wC.)
Co 10 - 0
0 9.5
Mean 18.2
oo
10 5 - oo
3.78
C
-Median 1.25
0 0
Normal Abnormal Normal Abnormal

Arteriography results Cavernosometry results

Fig. 2.-comparison of findings on pudendal arteriography with post- Fig. 3.-Comparison of results of cavemosometry with postpapaverine
papaverine peak systolic velocities in cavemosal arteries as measured by end-diastolic velocities in the cavemosal arteries as measured by Doppler
Doppler sonography in 12 patIents studied with both arteriography and sonographyin 57 patIents evaluated with both cavemosometry and Doppler
Doppler sonography. sonography.

I -:- -w:: “,
.. - . _;_. .1!

Fig. 4.-Patient with normal penile venous competence.

A, Normal cavemosogram shows contrast material In corpora cavemosa only (arrows).
B, Doppler sonogram before injection of papaverine shows minimal (approximately 15 cm/sec) peak systolic velocity and no detectable end-diastolic
velocity in right cavemosal artery.
C, Doppler sonogram after injection of papaverine shows peak systolic velocity of approximately 34 cm/sec, and no measurable end-diastolic velocity.

cavernosal arteries, measured by duplex sonography, was injection. Sixty-one patients had dynamic cavernosometry to
correlated with the findings on dynamic cavernosometry in an evaluate penile venous competence. Four of these patients
attempt to determine if increased end-diastolic velocity could had insufficient arterial inflow by sonographic examination
serve as an indicator of excess venous outflow (Fig. 3). These (mean peak systolic velocity, s25 cm/sec). Because we were
data indicate that patients with abnormal venous leakage on testing for venous disease, we considered only the patients
cavernosometry also often have increased Doppler end-dia- who had normal arterial inflow. Of these 57 patients, 16 had
stolic velocities in the cavemosal arteries. normal findings on cavernosometry and 41 had findings mdi-
The mean end-diastolic velocities in our 180 patients ranged cating abnormal venous leakage. Figures 4 and 5 are typical
from 0 to 11 cm/sec (average, 0.34) before injection of examples of cavernosograms and Doppler images of patients
papavenne and from 0 to 24.5 cm/sec (average, 5.6) after with normal and abnormal findings.
 1144 QUAM ET AL. AJR:153, December1989
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Fig. 5.-Patient with penile venous leakage.

A, Cavemosogram shows normal opaclfIcatlon of corpora cavemosa and crura penis and abnormal leak of contrast material out of penis through dorsal
penile veins and into periprostatic plexus (arrows).
B, Doppler sonogram before injection of papaverine shows measurable systolic and end-diastolic velocities.
C, Doppler sonogram after injection of papaverine shows abnormally high end-diastolic velocity of 18 cm/sec. This was interpreted as abnormal venous
leakage.

Postpapavenne priapism that required syringe decompres- 100

sion of the corpora cavemosa developed in three of the
patients who had normal findings on cavernosometry. These
three patients were therefore considered to have normal 80
penile hemodynamics. In all three, there was no measurable
end-diastolic velocity in the cavernosal arteries after injection
of papavenne. 60
>
From our data, we created a receiver-operating-character-
Cl)
istic curve based on a series of mean end-diastolic velocity C
a, 40
cutoff values that served to distinguish normal from excess Cl)
velocity. This plots sensitivity vs specificity as a function of
the chosen cutoff point. With each cutoff value, the sono-
20
graphic results were divided into normal and abnormal groups
and then compared with the results of cavemosometry to
evaluate sensitivity and specificity (Fig. 6).
0
0 20 40 60 80 100
Discussion Specificity
In 1 970,
Masters and Johnson [1 3] reported that impotence Fig. 6.-Recelver-operating-characterlstlc curve shows sensitivIty and
was caused by organic factors in only 5% of patients. Since specificity combinations at various measured end-diastolic velocity cutoff
then it has been shown that organic factors more frequently values as they compare with cavemosometric results. To maximize sen-
sitivity, a threshold value of greater than or equal to 5 cm/sec (arrow) was
are the cause of impotence. Various series have reported that chosen to represent an abnormally high mean end-diastOlic velocity.
30% [14-16] to 50% [17] and up to 80% [18] of cases of
impotence can be attributed to organic causes. This realiza-
tion has led to extensive research on the mechanism of penile pelvic trauma, and iatrogenic factors [1 4, 1 5]. After the phys-
erection, the causes of dysfunction, and the methods of ical examination and screening measurements of free and
clinically evaluating the multiple organic causes of impotence. total serum testosterone and glycosylated hemoglobin or
Evaluation of impotence should begin with a precise history glucose levels, certain specific diagnostic tests are done.
and medical workup to rule out the major causes of erectile These include nocturnal penile tumescence [19], penile-bra-
dysfunction. The most frequently associated abnormalities chial index [20], and, recently, pharmacologic induction of
include psychogenic factors, diabetes mellitus, atherosclero- erection by using intracavernosal injection of papaverine with
sis and other vasculidities, neuropathy, endocnnopathy, major or without phentolamine [21,22]. Evaluation then can proceed
 AJR:153, December1989 DOPPLER OF VASCULOGENIC IMPOTENCE 1145
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to the more invasive and more definitive digital subtraction erection is induced within 20 mm and lasts at least 30 mm,
angiography [23] or arteriography [24-26]for the assessment then the patient is thought to have sufficient arterial flow into
of penile arterial disease and dynamic cavemosometry and the penis and competent venoocclusive mechanisms. This
cavernosography [27-32] for the assessment of venous test does not distinguish arterial from venous disease if the
disease. patient does not respond.
Vascular disease is a leading cause of erectile dysfunction Pudendal arteriography allows a definitive evaluation of
and is potentially curable. Accurate diagnosis of vascular arterial disease but is a major undertaking for both the phy-
disease is thus crucial. Vascular anatomy and physiology of sician and the patient. It is performed by introducing a 5-
the penis are unique and complex. The blood supply of the French pigtail catheter through the femoral artery and ad-
penis is primarily via the internal pudendaJ arteries. Each vancing the tip to the low abdominal aorta. A nonselective
internal pudendal artery gives off a penneal branch, a bulbar pelvic angiogram is then obtained. If the vessels are normal
artery, and a very small urethral artery before continuing as proximally, then selective internal iliac artery catheterization
the artery of the penis. The artery of the penis branches into is performed. Just before catheter positioning, 60 mg (2.0 ml)
the cavernosal artery and the dorsal artery of the penis. The of papaverine are administered intracavernosally. A Bookstein
cavernosal arteries are involved with initiating and maintaining catheter (Cook, Inc., Bloomington, IN) is advanced through
erection; however, multiple anastomotic channels connect the the internal iliac artery origin into its anterior division and to
cavernosal arteries with the dorsal arteries and the very small the origin of the internal pudendal artery, if possible. Two
urethral arteries. The vascular anatomy of the penis is shown hundred to 300 g of nitroglycerin diluted in 10 ml of normal
in Figure 7. saline are administered slowly through the catheter over a
Arterial disease traditionally has been evaluated indirectly 30-sec interval. This is generally followed by 20-25 mg of
by using the penile-brachial index. This index, though, often tolazoline diluted in 1 0 ml of saline over 30 sec. Sixty to 90
is abnormal in patients without arterial disease and normal in sec after this medication is given, contrast material is injected
those with angiographically proved arterial lesions [33]. Phar- and filming is performed. The patient is positioned in the
macologic induction of erection by intracavernosal injection of contralateral oblique position (30-45#{176})
with the penis resting
papaverine with or without phentolamine recently has gained on the contralateral thigh (e.g., for injection of the right internal
wide acceptance in distinguishing vasculogenic from nonvas- pudendal artery, the patient is placed in the left posterior
culogenic impotence [21, 22]. Papavenne is a potent smooth oblique position with the penis resting on the left thigh).
muscle relaxant that acts directly on the penile arteries and Selective internal pudendal arteriography is certainly neces-
sinusoids. Its effect bypasses the psychoerotic and neurologic sary for definitive diagnosis and for preoperative arterial map-
stimuli normally necessary for erection, and thus injection of ping, but it cannot be used as a screening test for all patients
papavenne is considered an excellent and selective test of with suspected arteriogenic impotence.
penile vascular sufficiency. The papaverine is injected, and If arterial disease is excluded, excessive venous leakage is
the patient is observed for clinical response. If a full, firm often the source of erectile dysfunction. This can be con-
firmed with dynamic cavemosometry and cavernosography
[27-32]. This is performed by placing a 19-gauge needle into
each of the two corpora cavernosa. One needle is used for
intracorporeal infusion, and the other is connected to a ma-
nometer. Saline is infused at the rate required to initiate
erection and then decreased to a rate that maintains erection.
Intracavemosal pressures and infusion rates are then re-
corded. The procedure is then repeated after pharmacologic
induction of erection (intracavernosal injection of papaverine
with or without phentolamine), and pressures and infusion
rates are recorded again. Radiopaque contrast material is
infused and films are obtained of the penis and draining veins.
Greatest attention is given to the postpapaverine maintenance
infusion rates. In our study, if the infusion rate required to
maintain the erection was less than 30 mI/mm, the findings
were considered normal and the patient had no venous leak.
An infusion rate between 30 and 50 mI/mm signaled a minimal
leak, and if the required infusion rate was greater than 50 ml/
mm, then the patient was considered to have an excessive
venous leak. Those patients who had a minimal or excessive
leak detected by cavernosometry were included in the abnor-
mal cavemosometry group. Like artenography, dynamic cay-
ernosometry is a definitive study, but it is too invasive and
expensive to be a good screening examination.
Fig. 7.-Cross-sectional drawing of penis shows anatomic relationships
The introduction of duplex sonography and color Doppler
of penile arteries (a) and veins (v). imaging has provided an accurate and noninvasive means of
 1146 QUAM ET AL. AJR:153, December 1989
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assessing suspected vasculogenic impotence. The advent of of vessel diameter are in the assessment of vasculogenic
color Doppler imaging brings with it certain advantages over impotence.
standard duplex sonography. Both Lue et al. [7] and Collins The correlation of peak systolic velocities to arteriographic
and Lewandowski [9] described difficulty in detection and findings in our study was promising. The one discrepancy
often nonyisualization of some cavemosal arteries. The ad- was seen in a patient with subnormal peak systolic velocity
dition of color enhances the examiner’s ability to detect small by Doppler sonography and normal findings on arteriography.
vessels (e.g., cavernosal arteries). We were able to visualize This case was complicated by the patient’s history of three
and evaluate all 360 cavernosal arteries in our study. Correc- previous penile revascularization procedures. In addition, his
tion of the Doppler angle is also simpler and more accurate mean peak systolic velocity was 24 cm/sec, and hence only
because the color display of flow and vessel orientation is marginally subnormal. Because the technique for internal
seen throughout the image field. This ease of vessel detection pudendal arteriography has evolved over the last several
and correction of Doppler angle allows a more rapid and years, and because of the limited number of patients in this
accurate acquisition of data (Fig. 8). study, more work needs to be done correlating results of
Lue et al. [7] studied 21 patients and divided them into two specialized internal pudendal arteriography and duplex so-
groups. One group responded positively to intracavernosal nography. Our results, however, suggest that mean peak
papaverine injection and thus was considered to have normal systolic velocities of less than 25 cm/sec after the injection of
penile vasculature. The second group didnot respond to papaverine are highly suggestive of arterial disease and
papaverine and therefore was suspected of having penile should lead to more definitive evaluation with selective internal
vascular insufficiency. In this study, peak systolic cavernosal pudendal arteriography. Values between 25 and 30 cm/sec
artery velocities for the nonresponders ranged from 9 to 24 are borderline, and clinical correlation is recommended for
cm/sec; velocities in the normal responders ranged from 21 each individual case. Mean peak systolic velocities greater
to 38 cm/sec. In a later article, Mueller and Lue [1 2] specified than 30 cm/sec after injection of papaverine should be con-
that patients without vascular insufficiency should have a sidered normal.
mean peak systolic cavemosal artery velocity of more than Dynamic cavernosometry is the current diagnostic gold
25 cm/sec, when examined with duplex sonography after standard in the evaluation of penile venous competence. The
intracavemosal injection of papaverine. relationship between end-diastolic velocity in the cavernosal
We followed a similar study protocol, evaluating the diam- arteries and excess venous leakage has not, to our knowl-
eters of the cavernosal arteries and mean peak systolic edge, been considered in the literature. In patients who were
velocities after injection of papaverine. In addition, mean end- evaluated by both cavemosometry and sonography, our re-
diastolic velocities were measured. Because of the small size suIts show that measurement of end-diastolic velocity may
of the cavemosal arteries, the consequent potential error in be useful in the evaluation of patients with suspected venous
diameter measurement is significant. Also, a number of stud- leakage. In addition to the strong correlation between end-
ies [7-9] have suggested that the variation in penis size diastolic velocities and the findings on cavemosometry, the
and vessel diameter among patients produces overlapping fact that the three normal cases in which priapism developed
of values across clinical response categories. Because of showed no end-diastolic velocity further supports the possible
these problems, it is uncertain how valuable measurements correlation of increased end-diastolic velocity and abnormal
venous leakage.
Because excessive penile venous leakage is a curable
cause of impotence, it is desirable that the sonographic study
detects as much of this venous pathology as possible (i.e.,
the test should have a high sensitivity). On the basis of the
receiver-operating-characteristic curve, we therefore selected
a mean end-diastolic velocity of 5 cm/sec as an excessive
velocity. This yields a sensitivity of 90.2% (95% confidence
interval, 77-97%) and a specificity of 56% (95% confidence
interval, 30-80%). Those patients who have abnormally high
end-diastolic velocities would then have the necessary pre-
operative cavernosometry. Some specificity is sacrificed at
this high sensitivity. Thus, a small number of normal patients
who had falsely abnormal sonographic results would have to
undergo cavernosometry. Nonetheless, the goal is high de-
tection of a curable problem, so these few false positives
would be acceptable.
Possible explanations for our low specificity values may be
Fig. 8.-Longitudinal duplex Doppler sonogram related to the timing of diastolic velocity measurements. Ad-
obtained at base of penis shows use of color flow hering to protocols used in similar studies [7-9], we began
to correctly identify cavemosal artery (red) and ac-
curately align angle-correction cursor with axis of
our sonographic investigation 5 mm after intracavemosal
flow. injection of papaverine. Thus, the diastolic velocities in the
 AJR:153, December1989 DOPPLER OF VASCULOGENIC IMPOTENCE 1147
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cavemosal arteries were typically measured between 5 and impotence with intracorporeal injection of papavenne and the duplex
ultrasound scanner. Semin Urol 1985;3:43-48
1 5 mm after injection. Recent investigation indicates that in
9. Collins JP, Lewandowski BJ. Experience with intracorporeal injection of
some patients full tumescence may not be reached until up papavenne and duplex ultrasound scanning for assessment of arteriogenic
to 20 mm after injection. impotence. Br J Urol 1987;59:84-88
During early active tumescence in normal patients, the 10. Decal KM, Gingell JC, Skmore R, FOIIett DH. ApplicatiOn of computerized
penileartenal waveform analysis in thediagnosisofarteriogenic impotence:
cavernosal artery typically gives a low-resistance sonographic
an initial study in potent and impotent men. Br J Urol 1987;60:450-456
spectral pattern (i.e., prominent diastolic velocity). At full 11 . Mellinger BC, Vaughan ED Jr, Thompson SL, Goldstein M. Correlation
rigidity, the venoocclusive mechanism becomes fully engaged between intracavemous papavenne injection and Doppler analysis in im-
and the cavemosal artery returns to a high-resistance spectral potent men. Urology 1987;30:416-419
pattern (i.e., little or no diastolic velocity). Thus, if a normal 12. MUeller SC, Lue TF. Evaluation ofvasculogenic impotence. Urol Clin North
Am 1988;15:65-76
patient is studied before the time of full rigidity, excessively
13. Masters WH, Johnson yE. Human sexual inadequacy. New York: Little,
high end-diastolic velocity values would be seen on the Dop- Brown, 1970
pIer sonogram spectral pattern. This would therefore generate 14. Federman DD. Impotence: etiology and management. Hosp Pract 1982;
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15. Beutler LE, Gleason DM. Integrating the advances in the diagnosis and
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Conclusions Muftidisciplinary survey of erectile dysfunction. Can Med Assoc J
1982;128:1393-1399
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promising noninvasive method of examining patients with
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suspected vasculogenic impotence. The capacity to evaluate of arterial risk factors in 440 impotent men. Lancet 1985;1 :181-184
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parallel earlier data generated by using standard duplex so- diagnosis and treatment of impotence. In: William RL, Karacan I, Frazier
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Doppler imaging and conventional duplex sonography results Doppler study of impotence in diabetics. J Urol 1975;113:636-639
in an accurate and efficient examination. In addition, it now 21 . Abber JC, Lue TF, Orvis BA, McClure AD, Williams RD. Diagnostic tests
seems that this method may also provide a sensitive assess- for impotence: a comparison of papavenneinjection with the penile-brachial
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mary, and further studies with larger numbers of patients are 923-925
22. Virag A, Frydman D, Legman M, Virag H. Intracavemous injection of
necessary. The ability to evaluate both arterial and venous papaverine as a diagnostic and therapeutic method in erectile failures.
sources of impotence, coupled with its noninvasive nature Angiology 1984;35:79-87
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